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r T APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELTON AVE., STOCKTON, CA Telephone (209) 466-6781 VN, _ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No, 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address CiCJ RJ_ City � � Oh Lot Size 16 cti[ .ice : PM Owner's Name l 11 Address 96 21 9 tE 11/ tmg 2yk ZCi Phan.'"!Ll 1 Contractor a/ _ Address Z License No.aC?q-f 3 Phone oQ TYPE-OF-WELL/PUMP:-" -: W-WELL— --WELLREPLACEMENTX` —77DESTRUCTION-0--_ --- PUMP INSTALLATION _�W. - SYSTEM REPAIR ❑ OTHER ❑ i DISTANCE TO NEAREST: SEPTIC TANK .f_ n SEWER LINES DISPOSAL FLO./tiD PROP. LINE/_=;W FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r� ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia- of Well Casing c �TN / l `gDomestic/Private 11 Gravel Pack El Tracy Type of Casing _._ Specifications f-} Public ❑ Other ❑ Delta Depth of.Grout Seal r Type f Grouta_c- e-nx I i Irrigation -Approx. Depth 11 Eastern Surface Seal Installed b Repair Work Done ❑ Type of Pump H.P. State Work pone f Well Destruction ❑ Well Diameter Sealing Material (top 50') ,17 —Depth -- ' Filler Materials'Below 50') TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION LI DESTRUCTION 1 I (No septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence_ Commercial_ Other s Number of living units: Y° Number of bedrooms y Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfo" t Capacity No. Compartments -PKG. TREATMENT PLT. ❑ ► Method of Disposal «. �Diftance to-nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines` Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size_ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ^1 hereby.certify that_I_have_prepared this application and that the work will be_d_o_ne.in_accordance.w_ ith San Joaquin-county_ordinances,,state laws-and. rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must rqall for all required inspections. Complete drawing on reverse side. Signed Title: `y c- S • date: - FOR DEPARTMENT USE ONLY ) 'j Application Accepted by Date [ —�3 —J- Area Pit r Gr t Inspection �� Date i'�Final Inspection by 'U°�� Date X07- _ S_1? . — Additional-Comments:-0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104`x ❑ Tracy 635-6M51 y Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2669, Stk., CA 95201 FEE ;4 INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT-NO. ..EH 13-24(REV.1/Na) 11� Z EH 11-26